Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
How would you manage a patient diagnosed with squamous carcinoma involving the entire length of the vagina and extends into the vulva (introitus), who has severe vaginal stenosis?
If this is a vaginal lesion involving the vulva, it should be classified as vulva cancer and treated like so. Typically with ext beam boost to 66 to 70 Gy.
What dose would you use to treat unresectable basal cell carcinoma of the vulva?
I have treated one patient with 55 Gy in 20 Fx who is NED at 3 years post-RT. Had some acute RT toxicities similar to most vulvar cancers. Treated gross disease alone with small margin, as mentioned above.
Is there evidence to support or argue against intermittent fasting for cancer patients?
This is a complex topic with many permutations of dietary interventions similar to fasting such as calorie restriction and “fasting mimicking”, but as it pertains to pure fasting, I know of a few small studies which characterize fasting around the time of chemotherapy infusions (Raffaghello et al., ...
Given the criticism of GOG 88 and in light of various other recent data, would you deliver definitive XRT in place of inguinal lymph node dissection?
Despite GOG 88 findings, a number of retrospective studies have suggested that regional prophylactic RT is an effective method of preventing groin recurrences with minimal morbidity when appropriately delivered. (Combined across retrospective series, the incidence of groin recurrence following treat...
Which PARP inhibitor do you recommend for maintenance therapy in BRCA mutated ovarian cancer after primary chemotherapy and why?
Given the abundance of both efficacy and safety data available for Olaparib in this setting, I use Olaparib for maintenance therapy in BRCA+ ovarian cancer patients after primary chemotherapy. The 5-year PFS data from SOLO-1, confirming sustained benefit beyond the end of treatment, further speaks t...
How would you evaluate the right inguinofemoral lymph nodes in a female patient in her 30s with a 4 mm midline SCC of the vulva (depth of invasion 1.45 mm) and a PET-positive enlarged left inguinal node, for whom you plan to debulk the left inguinofemoral lymph nodes?
Both GROINSS V1 and GOG 173 excluded patients with a clinically suspicious inguinal node. Although they defined this as suspicious by physical exam, I include pre-operative PET imaging in my decision-making. In a patient with a unilateral enlarged, PET-positive inguinal node, I would do a full ingui...
How would you manage a bulky primary exophytic vulvar SqCC in a patient with uncontrolled but very long standing HIV disease?
I would first optimize HIV management and then plan for definitive RT (chemo) based on the CD4 count.
When do you prefer to use bolus for treating superficial tumors adjacent to or involving the skin surface, especially for complex surface anatomy in the pelvis, head/neck, and extremity regions?
There is not a single answer to this question, as it depends on the specifics of the geometry, treatment technique (photons vs. electrons, beam angles, energy used, etc.), depth and size of the tumor, and other technical factors. Since almost no one has access to superficial or orthovoltage X-rays w...
How long would you continue second line maintenance PARP inhibitor in a patient with recurrent stage IV BRCA+ ovarian cancer who had CR and remains NED?
For patients with platinum-sensitive relapsed ovarian cancer with a partial or complete response to platinum-based chemotherapy, niraparib, olaparib, and rucaparib are approved by the FDA for maintenance therapy. While PFS outcomes are improved with these agents regardless of BRCA mutation status, t...
What is your dose-fractionation for cylinder-based vaginal cuff HDR brachytherapy for an isolated vaginal cuff recurrence after whole pelvis EBRT with residual thickness of disease <5 mm?
I usually prescribe 5Gy x5. I don't prescribe to a fixed thickness but treat based on residual thickness seen on MRI using multichannel applicator.I lesion at apex then treat upper 2-3 cm of vagina Here is out paper describing technique and outcome in detailhttps://www.ncbi.nlm.nih.gov/pubmed/299299...